. 2021 Aug 3;22(10):1969–1988. doi: 10.1016/j.jamda.2021.07.027

Table 2.

Studies Describing Interventions

Citation	Country	Study Design	Subjects and Setting	Intervention	Outcomes Assessed	Relevant Findings
Arons et al (2020)¹⁶	USA	Observational, time series, cohort study using serial point-prevalence surveys	Skilled nursing facility, n = 76 residents (48 positive, 28 negative)	Symptom-based screening to identify new infections	RT-PCR for SARS-CoV-2, symptoms at time of testing, cycle threshold values of tests, prevalence, and doubling time	More than half of COVID-19–positive residents asymptomatic at testing; symptom-based screening ineffective
Bakaev et al (2020)⁴¹	USA	Observational, time series, cohort study using serial point-prevalence surveys	Integrated senior health care organization (long-term care, post-acute rehabilitation, assisted living units) 723-bed facility, mean age 89 y	Universal testing of residents	Assess transmission via weekly incidence	Universal testing and associated containment measures (cohorting, acute hospital partnership) effective in reducing incidence
Borras-Bermejo et al (2020)⁴²	Spain	Cohort study, test-based screening	Screening of 5869 nursing home staff and residents within a hospital catchment area in Catalonia, Spain; N = 69 facilities, N = 5869 persons	Test-based screening as containment measure	Positive or negative RT-PCR test for COVID-19 among symptomatic and asymptomatic residents and staff or nursing homes	High proportions of asymptomatic infection among residents and staff; importance of test-based screening rather than symptom-based approaches as part of prevention and control measures.
Belmin et al (2020)⁴³	France	Retrospective, cross-sectional cohort study	17 nursing homes, 794 staff members, 1250 residents	Staff confinement within facility	Confirmed and possible cases among residents and staff compared to national survey	Staff confinement may be effective in reducing number of staff and resident cases and resident mortality
Blain et al (2020)⁴⁴	France	Case investigation observational, cohort, time series	79 residents, 34 health care personnel in a single nursing home	Assess American Testing Guidance - nasopharyngeal testing done for all residents and staff and repeat weekly until no new cases identified	Proportion of staff and residents testing positive at baseline and weekly after that; seroconversion tested for all at 6 wk	Supports validity of updated testing guidance, and implementation of IPC in residents and staff with positive testing or symptoms. Asymptomatic staff with repeated negative tests can develop antibodies
Cabrera Alvargo et al (2020)⁴⁵	Spain	Prospective population-based cohort study	RT-PCR screening of institutionalized residents and workers in 306 care homes in Galicia, Spain; N = 25,386 individuals	Pooling strategy using RT-PCR	Prevalence of COVID-19; effectiveness of pooling strategy	Pooled testing of sample groups effective in rapidly detecting infected individuals in the context of low SARS-Cov-2 prevalence while preserving testing resources; once zero prevalence is achieved, successive rounds of pooling testing is useful for transmission control
Caspi et al (2020)⁴⁶	Israel	Case study, spatiotemporal analysis describing digital tool for mapping COVID-19	Assisted living facilities and nursing homes across Israel	Heat maps to quantify and predict spread and allow for tailored intervention	Heat maps (warm/red for cases; cold/blue for noncases) to quantify COVID-19 cases; trajectory of cases per facility	Heat mapping dashboard with interactive heat maps enabled prevention and containment by allowing “at-a-glance” picture to direct efforts, link outbreaks, and tailor disease mitigation steps; allowed policy makers to plan for hospital admission vs in-facility care, optimizing patient allocation
Collison et al (2020)⁴⁷	USA	Case study	Post-acute and long-term care skilled nursing facilities (SNFs), N = 120	Point-prevalence testing and 3-tiered cohorting as tool for mitigating an outbreak in SNFs	Incidence of COVID-19 in cohorts	Facility-wide point prevalence testing coupled with 3-tiered cohorting approach effective in halting spread of outbreak; separating exposed from unexposed negative-test individuals is crucial to stop horizontal transmission; separating residents into smaller rooms and increased staffing ratios on memory units may be potential strategies to decrease transmission when strict cohorting is not feasible
Dora et al (2020)⁴⁸	USA	Observational, time series, cohort study	Long-term care skilled nursing facility for veterans, N = 99 residents (>95% male)	Serial, universal testing of residents	Laboratory-confirmed positive test, symptoms at time of testing	Serial testing and cohorting effective
Dora et al (2020)⁴⁹	USA	Observational, time series, cohort study	Skilled nursing facility, N = 150 residents (26 positive on PCR, 77 negative on PCR, and 47 PCR-negative residents from a satellite campus)	Serial RT-PCR testing of residents with confirmation via serology	Alignment of nasopharyngeal SARS-CoV-2 (RT-PCR) results with seroconversion status	Serial testing followed by rapid isolation of symptomatic and asymptomatic residents effective at containing outbreak
Echeverría et al (2020)⁵⁰	Spain	Observational, longitudinal cohort study over 30 d	169 nursing homes and 27 institutions for people with physical and mental disabilities n = 10,000 institutionalized individuals and n = 4000 health care workers	COVIDApp providing real-time communication with primary care teams	RT-PCR, symptom status, mortality rates, suspected cases in HCWs, number of isolated health care workers	Decreasing prevalence but could be explained by parallel infection control methods
Eckardt et al (2020)⁵¹	USA	Observational, time series, cohort study using serial point-prevalence surveys	Hospital-affiliated long-term care facility n = 85-105 residents, 173-176 staff	Universal testing in residents and staff every 14 d, multidisciplinary acute care “strike team” for IPC education and support	Prevalence at 3 time points	Need for rapid identification and action to prevent spread and large scale outbreaks
Escobar et al (2020)⁵²	USA	Observational, time series, cohort study using serial point-prevalence surveys	Nursing home n = 84 residents (83 male)	Universal serial testing of residents and then staff (every 3-5 d), rapid resident cohorting	SARS-CoV-2 prevalence	Effective (in conjunction with other infection control measures)
Feaster and Goh (2020)⁵³	USA	Cross-sectional cohort study	8 skilled nursing facilities and 1 assisted living facility n = 1093 (608 residents, 485 staff)	Facility-wide testing of staff and residents in facilities with ≥3 linked cases	COVID-positive status and symptoms at time of testing	High proportion of asymptomatic infections, IPC measures should include mass testing in addition to symptom screening
Graham et al (2020)¹¹	UK	Observational, time series, cohort study using serial point-prevalence surveys	4 nursing homes n = 394 residents + convenience sample of asymptomatic staff	Comprehensive testing program for residents	Deaths, COVID-19 prevalence, and symptom profile at time of testing	Many residents with atypical or no discernible symptoms, plus asymptomatic staff, suggesting a role for regular screening
Guery et al (2020)⁵⁴	France	Observational, cross-sectional cohort study	Nursing home n = 136 staff members	Systematic screening of all staff members	Symptoms at time of testing	Symptom-based screening ineffective
Goldberg et al (2020)⁵⁵	USA	Cross-section cohort study	Nursing home residents (n = 97) and staff (n = 147)	Single universal testing of suspected asymptomatic population	RT-PCR–proven infection status with SARS-CoV-2	High proportion of asymptomatic infections—need for widespread testing among residents and staff coupled with intensive IPC to prevent spread of COVID-19; social distancing proved challenged, particularly for residents with dementia
Harris et al (2020)⁵⁶	USA	Descriptive intervention study, no control	Long-term care facility, residents (n = 48) and staff (n = ?)	Multidisciplinary telehealth-centered, multifactorial, COVID-19 facility outbreak strategy	Hospitalization, treatment in facility, mortality	Hospitalization and mortality reduced; multicomponent strategy including rapid identification of patients needing escalated care, care coordination, transfers, goal clarification for care outcomes, daily facility needs assessment
Hatfield et al (2020)⁵⁷	USA	Observational comparative study	7 state or local health departments that conducted facility-wide testing in 288 nursing homes	Comparison of statewide testing (n = 2, 195 nursing homes) and targeted testing (n = 5, 93 nursing homes) based on identified cases among residents or staff (n = 88) or high rates of community transmission (n = 5)	RT-PCR test results and association with cumulative incidence, adjusted for local epidemiology	Rapid facility-wide testing following case identification might facilitate control of transmission; strategies needed to optimize universal testing in the absence of reported cases
Jatt et al (2020)⁵⁸	USA	Observational, longitudinal, cohort study	A Veterans health integrated medical campus including a tertiary care center (160 beds), skilled nursing facility (150 beds), residential rehabilitation center (151 beds), and temporary shelter units for 218 homeless individuals (N = 1781 patients and residents)	Widespread laboratory surveillance followed by implementation of IPC measures to prevent disease transmission	In-house RT-PCR tests with external validation, symptom status	Importance of asymptomatic testing and widespread surveillance, in parallel with IPC
Kennelly et al (2020)⁵⁹	Ireland	Population-based, point-prevalence study	Nursing homes in Ireland (n = 45 nursing homes, n = 2043 residents)	Point-prevalence testing of residents and staff	Incidence of COVID-19	High prevalence among residents and staff, a significant proportion of which were asymptomatic or presymptomatic, highlighting the importance of systematic mass testing to reduce risk of transmission and contain outbreaks in LTCFs
Kimball et al (2020)⁶⁰	USA	Observational cohort study, outbreak investigation	Long-term skilled nursing facility; N = 76/82 residents	Facility-wide testing following case identification	RT-PCR; symptom assessment	Importance of asymptomatic testing and widespread surveillance, in parallel with IPC
Ladhani et al (2020)⁶¹	England	Observational cohort study	All residents (n = 264) and staff (n = 254) of 6 London care homes reporting COVID-19 outbreaks	Testing of residents and staff with follow-up for 14 d	RT-PCR; symptom assessment; mortality	High prevalence among residents and staff, with up to half asymptomatic; symptom-based screening alone insufficient for outbreak control
Lee et al (2020)⁶²	Korea	Observational cohort study, no control	A long-term care facility with a large exposure event; N = 211 participants (189 patients and 22 care workers)	Postexposure prophylaxis using hydroxychloroquine completed for 184 (97.4%) patients and 21 (95.5%) care workers	Baseline and follow-up tests at 14 d using RT-PCR; adverse events	All PCR tests negative at 14-d follow-up, with no serious adverse events reported
Lipsitz et al (2020)⁶³	USA	Longitudinal cohort study	360 Massachusetts nursing homes	28-item Infection Control Competency Checklist; payment incentive; on-site and virtual visits by infection control consultants; infection control weekly webinars; continuous Q&A communication from staff to infection control experts; PPE, staffing, and testing resources	Primary outcomes were the average weekly rates of new infections, hospitalizations, and deaths in residents and staff	Decreasing weekly rates of infections, hospitalizations and mortality; adherence to infection control processes, particularly proper wearing of PPE and cohorting, was significantly associated with reductions in weekly infection and mortality rates, suggesting role for payment incentives to improve infection control procedures
Louie et al (2020)⁶⁴	USA	Observational cohort study	4 long-term care facilities with COVID-19 outbreaks. N = 431 participants tested in initial outbreak responses; an additional 303 asymptomatic persons (147 HCWs, 48.5%) and 156 residents, 51.5%).	Mass testing in each facility following sustained transmission (≥1 new resident case ≥14 d after first case OR absence of epidemiologic link between HCW and resident case(s)	RT-PCR; symptom assessment	High proportion of asymptomatic infections, symptom-based screening alone insufficient; need for parallel IPC and policies supporting HCW to stay at home when exposed or unwell
Marossy et al (2020)⁶⁵	England	Observational cohort study, cross-sectional design over a 3-wk period	37 care homes in London (17 nursing homes, 13 residential homes, 1 mixed residential and nursing home, 6 extra care housing facilities; N = 2455; 1034 residents (42.1%) and 1421 staff (57.9%)	Point-prevalence testing	Nasopharyngeal testing with RT-PCR	High proportions of asymptomatic infection in staff and residents with underdetection of symptoms by care home staff, suggesting universal testing with rapid reporting of results would assist identification and facilitate prompt IPC action; analysis by facility type indicated some protection may be conferred by individual tenancy arrangements (ie, separate kitchen facilities, not sharing equipment, and a smaller number of carers)
Mcconeghy et al (2020)⁶⁶	USA	Retrospective cohort study	Cohort 1: 1301 residents in 134 facilities for Veterans in nursing homes; cohort 2: 3368 residents spread across 282 facilities in a private national chain of community NHs	Temperature testing and correlation with test-confirmed SARS-CoV-2 infection.	Sensitivity, specificity, and Youden index with different temperature cutoffs for SARS-CoV-2 PCR results	A lower threshold of 37.2°C improves sensitivity for identifying SARS-CoV-2 compared to standard test, triggering thresholds of 38.0°C; however, temperature is a poor independent diagnostic tool and should be used as part of a screening tool coupled with other signs and symptoms of infection
Mills et al (2020)⁶⁷	USA	Descriptive evaluation of mitigation measures implemented in 101 facilities	101 assisted living facilities in Ohio; N = 1794 residents, 74% female, mean age 88 ± 11 y	Comprehensive preparedness and suppression plan implemented by a home-based primary care group	Targeted testing for individuals with fever and lower respiratory tract symptoms, or with potential exposure to a confirmed or suspected case (n = 35); hospitalizations (n = 3); mortality (n = 1)	Components included a secure, cloud-based web application for case or exposure triage and reporting; isolation and IPC training and procedures adapted from US CDC; mobile-enabled screening app to prevent employees from attending work when ill
Park et al (2020)⁶⁸	South Korea	Retrospective cohort study (pooled outbreak investigations, n = 3)	Long-term care facilities, n = 3, all with an infected staff index case from an external source	Public health responses—testing, home quarantine, contact tracing, cohort quarantine	1 confirmed outbreak of 24 subsequent cases and 2 facilities with no further transmission	Early detection was the most important outbreak control method used in LTCFs; also recommended staff monitoring and management strategies, including individual distributed deployment
Rolland et al (2020)⁶⁹	France	Observational, prospective self-reported telephone survey	Long-term care facilities in regional France, N = 124	Compare application of recommended mitigation and infection control measures	Facility contamination with COVID-19 (1 or more residents or caregivers with RT-PCR confirmed infection)	Greater prevalence of COVID-19 in private facilities linked to better use of testing capability in those centers; staff compartmentalization within areas the main factor associated with COVID-19 infection in both public and private facilities
Rudolph et al (2020)⁷⁰	USA	Prospective cohort study	7325 residents in 134 community living centers for veterans	Temperature screening for COVID-19 detection	SARS-CoV-2 test (RT-PCR); temperature changes in daily clinical screening program before and after universal testing	Single temperature screening unlikely to detect COVID-19–positive residents; repeated measurement against a patient-derived baseline can increase sensitivity; current 38°C fever threshold for screening should be reconsidered
Sanchez et al (2020)⁷¹	USA	Cohort study; outbreak investigation and response across multiple facilities	2773 residents of 26 skilled nursing facilities in the Detroit area	Repeat mass testing to inform IPC practices, with onsite IPC support for facilities	SARS-CoV-2 test (RT-PCR, nasopharyngeal swab)	Repeated point-prevalence surveys in SNFs can identify asymptomatic cases, inform cohorting and IPC practices, and guide prioritization of health department resources
Shimotsu et al (2020)⁷²	USA	Observational time series, cohort study	LTCF (111 residents)	Regular symptom screening and surveillance testing of residents, employees, and visitors (coupled with IPAC measures)	Incidence of COVID-19 infections	Regular surveillance testing and symptom screening coupled with other containment measures effective in preventing spread of infection
Telford, et al (2020)⁷³ Telford et al (2020)⁷⁴	USA	Observational, cohort study	N = 5671; 2868 residents and 2803 staff in 28 long-term care facilities (15 with cases and 13 without)	Mass screening of residents and staff with support from the National Guard	SARS-CoV-2 test (RT-PCR, nasopharyngeal swab)	Significantly higher prevalence in facilities with known infection (28.9%) compared with those screened as a preventive measure (1.6%), P < .001; proactive testing of residents and staff members might prevent large outbreaks in LTCFs through early identification and timely IPC response
Verbeek et al (2020)⁷⁵	The Netherlands	Mixed methods cross-sectional study (questionnaire, phone interviews, document analysis, social media)	26 Dutch nursing homes	Cautious reopening to visitors according to national guideline, local protocols	Guideline compliance; impact on resident, family, and staff well-being; new COVID-19 cases	Visiting is valuable and can be safely reintroduced with specified preconditions for visitors and facilities, with stringent IPC measures
Wilmink et al (2020)⁷⁶	USA	Modelling study to describe development of digital contact tracing and assess system performance using simulation model	Hypothetical long-term residential care facility with 80 residents and 40 staff	Real-time digital contact tracing system designed for LTCFs (wearable device and network mapping software)	Cases and resultant deaths using simulation model	Digital contact tracing tools show promise, offer theoretically justified solution to facilitate implementation of regular IPC methods